Psychoeducation as Evidence-Based

Practice: Considerations for Practice,

Research, and Policy

Ellen P. Lukens, MSW, PhD

William R. McFarlane, MD

This paper describes psychoeducation and its applications for mental health and health
professions across system levels and in different contexts by reviewing the range of
applications that have appeared in the recent literature. The theoretical foundations of
clinically based psychoeducation are reviewed and the common elements of practice are
identified. Examples of well-defined psychoeducational interventions are presented that
meet criteria for empirically supported psychological interventions. In conclusion, the
broad applications of psychoeducation for health care and mental health practice and
policy at both the clinical and community levels are discussed, and the need for
further evaluation and research is considered. [Brief Treatment and Crisis Intervention
4:205–225 (2004)]

KEY WORDS: psychoeducation, group intervention, evidence-based practice,

randomized trials, brief treatment.

Psychoeducation is among the most effective of
the evidence-based practices that have emerged
in both clinical trials and community settings.
Because of the flexibility of the model, which
incorporates both illness-specific information
and tools for managing related circumstances,
psychoeducation has broad potential for many
forms of illnesses and varied life challenges.
From Columbia University School of Social Work (Lukens),
and Department of Psychiatry, Maine Medical Center
(McFarlane).
Contact author: Ellen P. Lukens, PhD, Columbia
University School of Social Work, 622 West 113th Street,
New York, NY 10025. E-mail: EL19@columbia.edu.
DOI: 10.1093/brief-treatment/mhh019
Brief Treatment and Crisis Intervention Vol. 4 No. 3, ª Oxford University Press 2004; all rights reserved.
This paper examines the research that supports
psychoeducation as evidence-based practice for
the professions dealing with mental health,
health care, and social service across system
levels and in different contexts by reviewing
the range of applications that have appeared in
the recent literature. We identified the psycho-
educational examples included in the review by
following guidelines for evidence-based prac-
tices created by the American Psychological
Association’s (APA) Task Force on Promotion
and Dissemination of Psychological Procedures
(1995). In the Discussion section, the common
and unique themes and content across studies
and populations are identified.

205
LUKENS AND MCFARLANE
Psychoeducation is a professionally delivered
treatment modality that integrates and syner-
gizes psychotherapeutic and educational in-
terventions. Many forms of psychosocial
intervention are based on traditional medical
models designed to treat pathology, illness,
liability, and dysfunction. In contrast, psycho-
education reflects a paradigm shift to a more
holistic and competence-based approach, stress-
ing health, collaboration, coping, and empow-
erment (Dixon, 1999; Marsh, 1992). It is based
on strengths and focused on the present. The
patient/client and/or family are considered
partners with the provider in treatment, on
the premise that the more knowledgeable the
care recipients and informal caregivers are, the
more positive health-related outcomes will be
for all. To prepare participants for this partner-
ship, psychoeducational techniques are used to
help remove barriers to comprehending and
digesting complex and emotionally loaded in-
formation and to develop strategies to use the
information in a proactive fashion. The assump-
tion is that when people confront major life
challenges or illnesses, their functioning and
focus is naturally disrupted (Mechanic, 1995).
Psychoeducation embraces several comple-
mentary theories and models of clinical prac-
tice. These include ecological systems theory,
cognitive-behavioral theory, learning theory,
group practice models, stress and coping
models, social support models, and narrative
approaches (Anderson, Reiss, & Hogarty, 1986;
Lukens, Thorning, & Herman, 1999; McFarlane,
Dixon, Lukens, & Lucksted, 2003). Ecological
systems theory provides the framework for
assessing and helping people understand their
illness or experience in relation to other systems
in their lives (i.e., partners, family, school,
health care provider, and policymakers). Under
this umbrella, psychoeducation can be adapted
for individuals, families, groups, or multiple
family groups. Although psychoeducation can
be practiced one-on-one, group practice models
206 Brief Treatment and Crisis Intervention / 4:3 Fall 2004
set the stage for within-group dialogue, social
learning, expansion of support and coopera-
tion, the potential for group reinforcement of
positive change, and network building (Pen-
ninx et al., 1999). They reduce isolation and
serve as a forum for both recognizing and
normalizing experience and response patterns
among participants, as well as holding profes-
sionals accountable for high standards of
service. Cognitive-behavioral techniques such
as problem solving and role-play enhance the
presentation of didactic material by allowing
people to rehearse and review new informa-
tion and skills in a safe setting. These can
be amplified through specific attention to the
development of stress management and other
coping techniques (Anderson et al., 1986;
McFarlane, 2002). Narrative models, in which
people are encouraged to recount their stories as
related to the circumstances at hand, are used to
help them recognize personal strengths and
resources and generate possibilities for action
and growth (White, 1989).
Recent mandates at both the federal and
international levels have pushed to include
psychoeducation as a focal point in treatment
for schizophrenia and other mental illnesses,
and are backed by national policymakers
(President’s New Freedom Commission on Men-
tal Health, 2003) as well as influential family
self-help groups such as the National Alliance
for the Mentally Ill (NAMI) (Lehman & Stein-
wachs, 1998; McEvoy, Scheifler, & Frances,
1999). Based on an exhaustive review of the
evidence-based literature on schizophrenia, the
Schizophrenia PORT (Patient Outcomes Re-
search Team) study recommended that educa-
tion, support, crisis intervention, and training
in problem solving be offered to available
family members over a period of at least 9
months (Lehman & Steinwachs, 1998). Best-
practice and expert panels corroborated these
recommendations (American Psychiatric Asso-
ciation, 1997; Coursey, 2000; Coursey, Curtis, &

Marsh, 2000; Frances, Kahn, Carpenter, Doch-
erty, & Donovan, 1998), given that remarkably
positive outcomes have been observed in over
25 independent studies (Dixon, Adams, &
Lucksted, 2000; Dixon et al., 2001; McFarlane
et al., 2003). Several outcomes of psychoeduca-
tional interventions for schizophrenia are
particularly noteworthy and have been dem-
onstrated across studies (McFarlane et al.,
2003). For persons receiving individual therapy
and medication, or medication alone, the 1-year
relapse rate ranges from 30% to 40%; for those
participating in family psychoeducation of at
least 9 months’ duration, the rate is about 15%
(Baucom, Shoham, Mueser, Daiuto, & Stickle,
1998). Other positive outcomes have been docu-
mented for patients and for families as well,
suggesting that psychoeducation provides mul-
tiple benefits. These include decreased symp-
tomatology and improved social functioning for
the patient (Dyck, Hendryx, Short, Voss, &
McFarlane, 2002; Dyck et al., 2000; McFarlane
et al., 1995; Montero et al., 2001) and improved
well-being and decreased levels of medical
illness among family members (McFarlane,
Dushay, Stastny, Deakins, & Link, 1996; Solo-
mon, Draine, & Mannion, 1996; Solomon,
Draine, Mannion, & Meisel, 1996).
In schizophrenia, any form of intervention is
complicated by the symptoms of the illness,
which include psychosis as well as functional
and cognitive deficit or distortion, alogia,
inertia, denial, and/or lack of awareness of
illness (American Psychiatric Association,
1994). Patients, formal care providers, and
informal caregivers are confronted not only
by the severe burden of the illness, but by the
distorted sense of reality by which it is
characterized. To address this multifaceted set
of challenges, the various psychoeducational
models for schizophrenia build on a series of
principles that exemplify the paradigm shift to
a strengths-based approach to intervention.
Key aspects of these approaches include service
Brief Treatment and Crisis Intervention / 4:3 Fall 2004
Psychoeducation as Evidence-Based Practice
coordination (i.e., easy access and clarity of
expectation regarding service, medication man-
agement and adherence, and crisis planning),
provision of relevant up-to-date information in
a timely and flexible manner, attention to
family conflict, communication, loss, problem
solving, and attention to social as well as
clinical needs for the person with illness, along
with expanded social support for the family,
through multiple family psychoeducation and
family support groups (e.g., NAMI) (Dixon
Adams, & Lucksted, 2000; McFarlane et al.,
1995; McFarlane et al., 2003).
Psychoeducational approaches also are well
established as adjunctive treatment for cancer,
where patients and families are struggling with
different forms of challenge. Although persons
with cancer typically fall into the normal range
in terms of psychological processes, they
inevitably struggle with the anxiety and de-
pression following the extraordinary stress
associated with the diagnosis and treatment of
the cancer (Cunningham, Wolbert, & Brock-
meier, 2000). Numerous randomized studies
over the last two decades have shown signif-
icantly increased quality of life and decreased
levels of anxiety and distress for persons with
cancer who participate in professionally led
psychoeducational groups (Cunningham, 2000;
Edmonds, Lockwood, & Cunningham, 1999;
Meyer & Mark, 1995). There is increasing
evidence that psychoeducational and other
forms of professionally led support groups can
have an impact on the longevity of cancer
patients as well (Cunningham, 2000; Cunning-
ham, Edmonds, et al., 2000; Fawzy, Fawzy,
Arndt, & Pasnau, 1995; Richardson, Shelton,
Krailo, & Levine, 1990; Richardson, Zarnegar,
Bisno, & Levine, 1990; Spiegel, Bloom, Kraemer,
& Gottheil, 1989). This reinforces the value and
importance of emotional support and enhanced
coping in the face of any form of severe illness.
Families and other informal caregivers of
persons with cancer have been targeted as well.
207
LUKENS AND MCFARLANE
In one recent study focusing solely on partners
of women with early-stage breast cancer, par-
ticipants in psychoeducational groups showed
less mood disturbance 3 months posttreatment
than controls, and the women whose partner
participated reported less personal mood dis-
turbance and more emotional support (Bultz,
Speca, Brasher, Geggie, & Page, 2000). These
women also described significantly more stable
marital relationships over time, suggesting that
the psychoeducational groups served a preven-
tive function.
The number of well-documented evidence-
based studies on psychoeducation as an
intervention for illnesses as different as schizo-
phrenia and cancer suggests the potential for
the model. There is significant evidence that
psychoeducational interventions are associated
with improved functioning and quality of life,
decreased symptomatology, and positive out-
comes for both the person with illness and
family members as well.
However, there has been little attempt to
examine the breadth of applications in other
psychiatric, medical, or clinical settings. The
aim of this paper is to review and discuss the
range of psychoeducational interventions for
other settings and circumstances using ac-
cepted criteria for designating a practice inter-
vention as evidence based.
Method
Our approach is twofold: first, to show the
breadth of application for psychoeducational
interventions, and second, to include studies
that follow the criteria for empirically sup-
ported psychological interventions devised by
the Task Force on Promotion and Dissemination
of Psychological Procedures (1995). These
guidelines have been supported and amplified
by other investigators and reported on by
Chambless and colleagues (Chambless & Hollon,
208 Brief Treatment and Crisis Intervention / 4:3 Fall 2004
1998; Chambless & Ollendick, 2001). Broadly
defined, these criteria are grouped as:
Category I: established, efficacious, specific
interventions, including two rigorous
randomized trials conducted by indepen-
dent investigators;
Category II: probably or possibly efficacious
intervention, treatment compared with
wait-list control; and
Category III: experimental treatments that do
not meet the above criteria for adequate
methodology.
In addition, the task force determined that
Category I interventions should follow a treat-
ment manual or clearly prescribed outline for
treatments and that the characteristics of the
sample should be specified (Chambless &
Hollon, 1998). Nathan and Gorman (1998)
extend the characteristics for Category I studies
to include blind assessment of research subjects
by independent raters, specific inclusion and
exclusion criteria, up-to-date diagnostic assess-
ment, and adequate statistical power.
Studies selected for inclusion in this review
were retrieved through a search of PubMed and
PsychInfo from 1995 until the present. This
time period was selected because of increased
attention to selection criteria for evidence-
based practice that has emerged since 1995
(Chambless & Hollon, 1998; Chambless &
Ollendick, 2001; Rousanville, Carroll, & Onken,
2001). Key search words included psychoeduca-
tion, psychoeducational groups, randomized trial,
control group, clinical trial, controlled trial, and
outcome. The intent was to identify studies that
would meet criteria for Category I, as described
above.
For the purposes of this review, the following
criteria were used for the selection of published
studies described as using a psychoeducational
intervention:

The article focused on one or more inter-
ventions targeting a specific and clearly
defined mental illness, medical illness, or
other form of personal life challenge (e.g.,
partner abuse).
At least one of the interventions labeled as
an active treatment was described as
psychoeducational in nature, targeting
either the family, the person challenged
by the illness or life situation, or both.
The psychoeducational intervention was
presented in person (as opposed to online
or solely through written material).
The design of the study involved random
assignment to the active psychoeduca-
tional treatment intervention and to
a control group. (Note that in one in-
stance, reports of randomized trials in
process are included in the review as well,
because they are based on a well-docu-
mented and randomized pilot study [Fris-
tad, Gavazzi, & Mackinaw-Koons, 2003;
Fristad, Goldberg-Arnold, & Gavazzi,
2003]).
The article provided enough information to
assess the quality of the research design
and methods and the applicability and
relevance of outcome measures.
The article provided enough information to
assess the nature and extent of the
psychoeducational intervention, to deter-
mine whether psychotherapeutic and
educational techniques were integrated.
Intervention studies in which the authors
referred to a seemingly straightforward
educational intervention (i.e., with no
psychotherapeutic component) as psy-
choeducational in nature were excluded.
One article was not reviewed because the
term psychoeducation was referred to in the title
and abstract but not in the text of the article
Brief Treatment and Crisis Intervention / 4:3 Fall 2004
Psychoeducation as Evidence-Based Practice
(Shelton et al., 2000). A second was excluded
because a psychoeducational group was used as
a minimally defined control intervention (Lati-
mer, Winters, D’Zurilla, & Nichols, 2003), and
a third because psychoeducation was referred
to as a combination placebo/usual care control
with no description as to form or content
(Kaminer, Burleson, & Goldberger, 2002).
Applications for Mental Health
Conditions Other Than Schizophrenia
Although reports of randomized trials of
psychoeducation for adults coping with schizo-
phrenia are well represented in the literature,
adaptations for children and adolescents and for
adults with other serious mental health con-
ditions are just beginning to appear (see Table
1). Fristad and her colleagues piloted multiple
family psychoeducational groups with break-
out sessions for children aged 8 to 11 with mood
disorders (including both bipolar disorder and
major depressive disorder/dysthymia as com-
pared with wait-list controls [Fristad, Gavazzi,
& Soldano, 1998; Fristad, Goldberg-Arnold, &
Gavazzi, 2002]). These groups focused on both
parent and child outcomes, including caregiver
knowledge, increased caregiver concordance
regarding diagnosis and treatment, decreased
expressed emotion in parents and environmen-
tal stress for the child, and reduced symptom
severity and duration for the child. The cur-
riculum particularly attended to information
dissemination, the building of advocacy and
communication skills, both within the family
and across systems, and strategies for social
problem solving and symptom management.
Outcomes were positive, with families engaged
in the psychoeducational groups showing
significantly more knowledge about mood
symptoms, increased use of support services,
and increased reports of parental support by
children, both immediately after and 4 months
209
 LUKENS AND MCFARLANE
210

TABLE 1. Mental Health Conditions

Active (PE) Significant

Brief Treatment and Crisis Intervention / 4:3 Fall 2004

Treatment Structure Outcomes

Study Sample/Dx Design Protocol and Duration for PE Commenta

Colom Outpatients Randomized trial: Symptoms, course, 21 sessions Reduced # total Category II.
et al., 2003 diagnosed with PE groups vs. communication, & relapse & # Well-designed study
bipolar I & II disorder. nonstructured coping skills relapses/person.
Conducted in Spain group meetings Increased time to
recurrence; fewer
& shorter
hospitalizations
Dowrick Adults with Randomized trial; Relaxation, 12 two-hour Both active Category II.
et al., 2000 depression group PE vs. positive thinking; sessions over 8 interventions Separates PE &
in community individual problem social skills weeks w/class reduced caseness problem solving
solving vs. controls. reunions & improved
N = 452 subjective function.
Problem solving
more well received
Fristad et al., Children with Pilot study; Decrease in symptoms; Multiple family Improved family Category II
1998, 2002 mood disorders randomized improve coping & groups with climate
trial in process communication; break-out groups
stress management; for children/
expanded social supports adolescents.
Late afternoon &
evening
Honey Women Randomized trial: PE Coping strategies 8 sessions Tx group less Category II
et al., 2003 diagnosed with groups for women vs. related to child depressed at
postnatal standard tx. N = 45 care & obtaining posttest &
depression social support; 6-month fu,
cognitive-behavioral controlling for
techniques & antidepressants
relaxation
 TABLE 1 continued. Mental Health Conditions

Active (PE) Significant

Treatment Structure Outcomes
Study Sample/Dx Design Protocol and Duration for PE Commenta

No differences
re social support,
strength of
marriage, or coping
Miklowitz Persons with Randomized trial; PE, with focus on 21 individual Patients showed Category II.
et al., 2003 bipolar disorder & individual PE for communication & sessions w/ family fewer relapses. Well-designed study
family families vs. crisis problem-solving & patient over Longer survival,
intervention for training 9 months greater reduction
Brief Treatment and Crisis Intervention / 4:3 Fall 2004

families. in mood disorder

All patients symptoms & better
received medication. medication
N = 101 compliance
Peterson Women Randomized trial; Review of PE 14 one-hour All active tx Category II.
et al., 1998 with binge therapist-led PE vs. information, stress group sessions showed decrease Small sample
eating disorder partial self-help vs. management, over 8 weeks in binge eating size per cell;
structured self-help vs. homework at posttest group randomization.
wait-list control. Manual based

Psychoeducation as Evidence-Based Practice

N = 61
Rea et al., 2003 Outpatients Randomized trial; PE about bipolar 21 one-hour Patients less Category II.
diagnosed individual family disorder, communication sessions likely to be Well-designed study.
with bipolar I PE vs. individual tx enhancement, problem hospitalized; Manual based
disorder & for patient. N = 53 solving. fewer relapses
their families As-needed crisis over 2 years
intervention
Note: Dx = diagnosis; PE = psychoeducation; tx = treatment; fu = follow-up.
a
Chambless criteria for evidence-based practice (Chambless & Hollon, 1998).
211
LUKENS AND MCFARLANE
posttreatment. Interestingly, parents reported
increased positive family interactions, but not
decreased negative family interaction.
The authors successfully included children
with two different diagnoses (bipolar disorder
and major depression/dysthymia) in each
group. This represented an accommodation to
practicality (i.e., ease of scheduling), and
families appeared to benefit from learning about
both disorders. Fristad and colleagues recently
reported on two randomized trials to test two
variations on the pilot; one that serves families
through eight multiple family psychoeduca-
tional groups, and a second parallel model that
includes 16 individual family psychoeducation
sessions (parent-only meetings alternating with
child sessions in which parents join at the
beginning and end of the session) (Fristad,
Gavazzi, et al., 2003; Fristad, Goldberg-Arnold,
et al., 2003).
Honey, Bennett, and Morgan (2003) tested
a brief psychoeducational group intervention
for postnatal depression, randomly assigning
45 Welsh women scoring above 12 on the
Edinburgh Postnatal Depression Scale to an
eight-session psychoeducational group or to
routine treatment. The partner was not in-
volved. Although not manual based, the in-
tervention followed a prescribed curriculum
and included coping strategies related to child
care and obtaining social supports, cognitive-
behavioral techniques, and relaxation. At post-
test and 6 months posttreatment, women in the
psychoeducational groups showed significantly
decreased scores on the depression measure,
controlling for antidepressant use. However, no
differences occurred in terms of improved
social support, marital relationship, or coping
in analyses of effects for time, group, or Time !
Group interaction.
Several studies addressed the needs of
persons diagnosed with depression or bipolar
disorder living in the community. In a three-
armed study, Dowrick and colleagues (2000)
212 Brief Treatment and Crisis Intervention / 4:3 Fall 2004
compared group psychoeducation (12 two-hour
sessions over 8 weeks), 6 individual problem-
solving sessions conducted at home and con-
trols. The authors found that the two active
interventions reduced symptoms and improved
subjective functioning. The patients particu-
larly liked the individual problem-solving
sessions. Interestingly, the authors utilized
problem solving as a treatment independent
of psychoeducation. This is in contrast to most
of the studies reviewed, which specifically
incorporated problem-solving techniques with-
in the definition of psychoeducation.
In a study conducted in Spain of outpatients
diagnosed with bipolar disorder type I and II,
Colom and colleagues (2003) compared the
impact of 21 psychoeducational group sessions
with nonstructured group meetings. Partici-
pants in the active treatment were less likely to
relapse overall, had fewer relapses per person,
increased their time to recurrence of symp-
toms, and had both fewer and shorter hospital-
izations. In a relatively small study (N ¼ 53),
Rea and colleagues (2003) compared outcomes
for patients involved in 21 individual family
psychoeducation sessions with standard in-
dividual treatment. Participants in the family
psychoeducation sessions were less likely to
relapse or be hospitalized over the 2-year
study. In a separate, larger study, Miklowitz,
George, Richards, Simoneau, and Suddath
(2003) randomized 101 individuals with bi-
polar disorder to either 21 individual psycho-
educational family sessions or crisis
management (2 educational sessions plus crisis
sessions as needed). The patients in the
psychoeducational treatment showed fewer
relapses overall, longer symptom-free periods,
fewer symptoms, and better medication com-
pliance. Both of these studies were manual
based, with similar design, method, approach,
and outcome. However, the studies together
cannot be labeled as meeting criteria for
a Category I evidence-based practice because

they share an investigator (Chambless &
Hollon, 1998).
Peterson and colleagues (1998) used a psycho-
educational intervention for women with binge
eating disorder, comparing it with three other
treatment conditions (partial self-help, struc-
tured self-help, and a wait-list control). This
was the only study reviewed in which partic-
ipants in the psychoeducational intervention
did not show superior outcomes over time.
Rather, participants in all active treatments
showed a decrease in binge eating immediately
posttreatment. The authors noted several
threats to the validity of their study: random-
ization that targeted groups rather than indi-
viduals, small sample size (N ¼ 61), and lack of
follow-up data.
Applications for Caregivers of Persons
With Mental Health Conditions
Two studies particularly addressed the needs of
caregivers (see Table 2). Hebert and colleagues
(2003) tested the efficacy of a 15-session series
of psychoeducational groups for informal care-
givers of persons with dementia in comparison
with traditional support groups. Randomiza-
tion involved 158 individuals stratified by sex
and kinship status at several different sites. The
psychoeducational content in the curriculum
was focused on stress appraisal and coping.
Primary outcome measures were blindly as-
sessed and included frequency and response to
behavioral problems among care receivers;
secondary measures included patient burden,
distress and anxiety, perceived social support,
and self-efficacy. Immediately following the
intervention, those assigned to the psycho-
educational groups reported significantly less
reaction to behaviors and a trend toward less
frequency of reported behavior problems
among the family members with dementia.
The interaction between behavior frequency
Brief Treatment and Crisis Intervention / 4:3 Fall 2004
Psychoeducation as Evidence-Based Practice
and reaction also showed a significant decrease
for caregivers who received psychoeducation.
However, there were no significant differences
between groups for the secondary patient-
outcome measures.
In a small study conducted in southern India,
Russell, al John, and Lakshmanan (1999)
randomly assigned 57 parents of children with
intellectual impairment to either an active
psychoeducational group intervention or an
untreated control group. Participants in the 10-
session groups showed significantly improved
parental attitude regarding child rearing and
management of the disability immediately
posttest.
Applications for Medical Illness
Psychoeducational programs have also been
devised for medical illnesses, including acute
and life-threatening illnesses other than cancer,
as well as more chronic conditions. These
programs aim to help both the persons affected
and their caregivers or partner weather both
the physical and the psychological impact of
chronic and acute illness (see Table 3).
In one of the cross-national studies identified
through this review, researchers in Hong Kong
(Cheung, Callaghan, & Chang, 2003) randomly
assigned 96 women aged 30 to 55 preparing for
elective hysterectomy to either individual
psychoeducational sessions (information book-
let plus cognitive interventions focusing on
distraction and reappraisal) or a control group
(information booklet without additional in-
formation). Number of sessions, duration, and
intensity for the experimental group were not
specified and it was difficult to tell how well
integrated the educational component was with
the cognitive techniques in the psychoeduca-
tional intervention. However, women receiving
the active treatment reported significantly
lower anxiety and pain and higher treatment
213
 LUKENS AND MCFARLANE
214
Brief Treatment and Crisis Intervention / 4:3 Fall 2004

TABLE 2. Caregivers of Persons With Mental Health Conditions

Active (PE) Significant

Treatment Structure and Outcomes
Study Sample/Dx Design Protocol Duration for PE Commenta

Hebert Informal caregivers Multisite Stress appraisal 15 sessions Tx group shows Category II
et al., 2003 of persons with randomized trial; and coping less reaction to
dementia PE groups vs. behavior of patient,
traditional support less frequency of
groups. N = 158 reported problem
stratified by sex behaviors. No
& kinship status difference in burden,
distress & anxiety,
perceived social
support, or self-efficacy
Russell Parents of Randomized trial; Interactive 10 sessions Tx group showed Category II.
et al., 1999 children with PE groups for group PE improved parental Small total
intellectual parents vs. control attitude re child sample size
disability. group. N = 57 rearing & management
Conducted in of disability
southern India
Note: Dx = diagnosis; PE = psychoeducation; tx = treatment.
a
Chambless criteria for evidence-based practice (Chambless & Hollon, 1998).

satisfaction than those in the control group in
the days immediately postoperative. There was
no difference between the two groups in
requests for painkillers postsurgery.
Two additional models addressed chronic
medical problems, specifically obesity and
generalized pain. Ciliska (1998) randomly
assigned 78 women with obesity to a small-
group psychoeducational intervention (6 to 8
people per group), to an education-alone group
using a classroom format (16–20 people), or to
an untreated control group. The model empha-
sized problem solving and assertiveness train-
ing, with attention to etiology, risks and
benefits; and the relationship between body
image and self-esteem. Immediately posttreat-
ment, the psychoeducational subjects showed
significantly increased self-esteem, body satis-
faction, and more restrained eating patterns
compared with participants in either of the two
other groups. Outcomes for participants in the
education-alone intervention did not differ
from those in the control group.
Unremitting physical pain is associated with
depressive symptoms such as distress, hope-
lessness, and despair and contributes to dis-
ruption in both individual and family
functioning. To address this set of problems,
LeFort, Gray-Donald, Rowat, and Jeans (1998)
devised a 12-hour psychoeducational model
adapted from the Arthritis Self-Management
Program (Lorig, 1986) for persons confronted
with chronic pain. Curriculum was focused on
facts and myths regarding pain, medication,
depression, and nutrition in the context of
problem solving, communication skills, and
mutual support. The authors randomly as-
signed 110 individuals diagnosed with chronic
pain (mean duration of pain, 6 years) to either
the psychoeducational groups or a 3-month
wait-list control. Immediately posttreatment,
the group participants showed significantly
reduced indicators of pain and dependency,
improved physical functioning, vitality, gen-
Brief Treatment and Crisis Intervention / 4:3 Fall 2004
Psychoeducation as Evidence-Based Practice
eral life satisfaction, and self-efficacy, and
a trend toward improved mental health and
social functioning. No differences emerged
between the groups either in terms of de-
pression and uncertainty regarding future
functioning or on measures from the Medical
Outcomes Short Form (Ware & Sherbourne,
1992) on physical functioning and general
health. It is noteworthy that those who
dropped out or refused the active treatment
(8%) appeared to be more affected by pain (i.e.,
unable to sustain employment) than those who
enrolled and participated (LeFort & Steinwachs,
1998). This suggests that the experience of
severe pain may interfere with willingness or
ability to participate in a group intervention.
Olmsted, Daneman, Rydall, Lawson, & Rodin
(2002) assigned 85 adolescent girls diagnosed
with type I diabetes and comorbid disturbed
eating patterns and their parents to either
a series of six psychoeducational group sessions
or a treatment-as-usual control group. The girls
and parents participated in separate but parallel
sessions. At 6-month follow-up, the girls in the
active treatment continued to show significant-
ly reduced eating disturbance compared with
the controls.
Applications for Other Clinical Settings
and Prevention
Programs designed for other life concerns
familiar to social service agencies, exclusive of
those directly related to either psychiatry or
medicine, have also begun to appear in the lit-
erature (see Table 4). Gibbs, Potter, Goldstein,
and Brendtro (1996) created a manual-based
psychoeducational program for adolescents in-
carcerated in a medium security youth correc-
tional facility. The psychoeducational groups
met daily and focused on mediation, skills
and values enhancement, and peer support.
Adolescents were taught to recognize negative
215
 LUKENS AND MCFARLANE
216

TABLE 3. Medical Illness

Significant
Brief Treatment and Crisis Intervention / 4:3 Fall 2004

Active (PE) Treatment Structure and Outcomes

Study Sample/Dx Design Protocol Duration for PE Commenta

Cheung Women age 30 Randomized trial; Information plus Not specified Tx group Category II.
et al., 2003 to 35 preparing individual PE sessions cognitive intervention lower Extent and nature
for elective vs. control group (info with attention to anxiety & pain; of PE not defined
hysterectomy booklet only). N = 96 distraction & reappraisal higher tx
of circumstance satisfaction.
No difference in
request for pain
medicine
postsurgery
Ciliska, 1998 Women with Randomized trial Education about obesity; 12 sessions over Tx group increased Category II
obesity comparing PE problem solving, 12 weeks; 2-hour self-esteem &
group, education assertiveness training; sessions; 6#8 women restrained eating;
alone, & control. body image work; increased body
N = 78 group support satisfaction
LeFort People with Randomized trial Definitions of pain, 6 weeks, 12 hours Short-term Category II.
et al., 1998 chronic comparing PE myth busting; improvement Well-defined study
physical pain group w/ 3-month cognitive-behavioral of pain severity
wait-list control. techniques; pain & impact, role
N = 110 management; group functioning &
problem solving; involvement, life
communication satisfaction,
skills & mutual support self-efficacy,
resourcefulness;
decreased dependency.
No difference
re depression,
uncertainty, general
health, or physical
functioning
 Psychoeducation as Evidence-Based Practice

social behavior both in themselves and among

Manual based
Category II.
Commenta
their peers and to replace these behaviors
with more constructive and affirmative re-
sponses and actions. In a randomized pilot
study, participants in the psychoeducational
Reduction in eating groups were described as dramatically easier to
manage, with significantly improved social
maintained at skills and adjustment and decreased antisocial
disturbance;

6-month fu
Significant
Outcomes

behavior. However, sample size, duration of

for PE

treatment, and time to follow-up were not

specified.
In a small randomized trial conducted in
Hawaii, Kubany, Hill, and Owens (2003)
6 weekly 90-minute

assigned 37 ethnically diverse women with

sessions for girls
Separate group
group sessions.
Structure and

both a history of partner abuse and a diagnosis

and parents

of posttraumatic stress disorder (PTSD) to either

Duration

an individually based psychoeducational pro-

gram or a wait-list group. Most of the women
(32) eventually completed the program. The
active intervention incorporated 8 to 11 in-
Active (PE) Treatment

dividual one-and-a-half-hour sessions, focusing

on explorations of trauma history, stress man-
agement, monitoring of negative self-talk, as-
sociocultural
PE content,

influences,

symptoms
to control
strategies

sertiveness, managing contact with the abuser,

Protocol

and strategies for self-advocacy and avoid-

ing revictimization. At posttreatment and 3-
month follow-up, 94% of the women no longer
Chambless criteria for evidence-based practice (Chambless & Hollon, 1998).
Note: Dx = diagnosis; PE = psychoeducation; tx = treatment; fu = follow-up.

met criteria for PTSD. Moreover, they showed

Randomized trial

group w/ tx as
comparing PE

usual. N = 85

significantly reduced depression, guilt, and

shame, and increased self-esteem. In contrast,
Design

those women assigned to the wait-list group

showed no changes in scores for any measure at
the second pretest. Although the sample size
was extremely small, the authors documented
diabetes & disturbed

positive results across ethnic groups, suggest-

TABLE 3 continued. Medical Illness

Adolescent girls

eating attitudes

ing that the themes addressed in the psycho-

and parents
& behavior,
Sample/Dx

with type I

educational groups (i.e., male dominance and

the status of women relative to men) were
universal issues.
Another study involved groups of partici-
pants from the general population and was
et al., 2002

designed to promote health attitudes and

Olmsted
Study

behaviors regarding nutrition and as a pre-

ventive technique for the development of
a

Brief Treatment and Crisis Intervention / 4:3 Fall 2004 217

 LUKENS AND MCFARLANE
218
Brief Treatment and Crisis Intervention / 4:3 Fall 2004

TABLE 4. Other Clinical Settings and Prevention

Active (PE) Significant

Treatment Structure and Outcomes
Study Sample/Dx Design Protocol Duration for PE Commenta

Gibbs Antisocial youth/ Randomized PE Strengths-based; Daily meetings, 60#90 Pilot data: Active tx: Clear summary of
et al., 1996 medium-security group vs. control. peer group mediation, minutes; 7#9 youth. 15% recidivism at theory & conceptual
youth correctional Pilot data; N not skills training, anger Duration & leadership 6 mos. & 1 year. model
facility reported management, moral not described Controls: 30% at
education 6 mos.; 41% at 1 year
Kubany Women with Randomized Exploration of 8 to 11 At posttx, 94% did Category II.
et al., 2003 hx of partner individual PE trauma hx, stress hour-&-half not meet PTSD criteria; Small sample
abuse plus PTSD sessions vs. management, sessions reduced depression,
wait-list control. assertiveness, guilt, shame, increased
N = 37 managing contact self-esteem.
with batterer, Wait-list controls
strategies for showed no change
self-advocacy & at second pretest
avoiding victimization
Rocco Adolescent girls Random assignment Focus on normal 9 monthly Tx group showed Prevention-oriented
et al., 2001 in affluent high to PE groups vs. developmental sessions reduced bulimic study; nonclinical
school in Italy; no-group controls transitions, risk factors attitudes, tendency sample
prevention of for eating disorders, to asceticism,
eating disorders social challenge, ineffectiveness, anxiety, &
body shape, & weight fears about maturity
Note: Dx = diagnosis; PE = psychoeducation; tx = treatment; hx = history; PTSD = posttraumatic stress disorder.
a
Chambless criteria for evidence-based practice (Chambless & Hollon, 1998).

eating disorders (see Table 4). Rocco, Ciano, and
Balestrieri (2001) randomly assigned adolescent
girls from an affluent high school in Italy to
receive either nine monthly sessions in in-
tensive psychoeducational groups or no in-
tervention. The program targeted normal
developmental transitions as well as known
risk factors for eating disorders, with attention
to body shape and weight, social challenges,
and academic achievement. Compared with the
controls, participants showed reductions in
bulimic attitudes, in tendency to asceticism,
and in feelings of ineffectiveness, as well as
lowered anxiety and fears about maturity.
Discussion
In reviewing this relatively small number of
studies, it is clear that all fall into Category II in
terms of the APA criteria for evidence-based
practice (Chambless & Hollon, 1998; Chambless
& Ollendick, 2001; Task Force on Promotion
and Dissemination of Psychological Procedures,
1995). None of the studies reviewed would meet
the criteria for Category I, because they either
are not sufficiently rigorous, have not been
replicated by independent investigators, or
both. However, reviewing the limitations and
strengths of these studies is instructive so
that potential investigators can anticipate the
challenges involved in designing and conduct-
ing effective psychoeducational interventions
across diagnostic groups and settings.
Limitations and Strengths of the Studies
The assessment tools and methods that are
common across the studies identified in this
paper extend our understanding of how
psychoeducational interventions can be consis-
tently evaluated. Several recurring parameters
of measurement for assessing the impact of
psychoeducation on participants and signifi-
Brief Treatment and Crisis Intervention / 4:3 Fall 2004
Psychoeducation as Evidence-Based Practice
cant others can be identified from this group of
studies (see Tables I through IV) and are
consistent with those used in the work on
schizophrenia and cancer. These include
changes in symptoms (i.e., symptom reduction
specific to the targeted illness or situation),
decreased anxiety and depression (regardless of
problem and setting), and less time between
acute episodes of illness. They also include
increased adherence to and overall satisfaction
with medication and treatment, knowledge,
self-esteem and resources, family/marital cli-
mate or adjustment, and quality of life.
However, measures of process—including
attendance, dropout, turnover, training of
facilitators, and fidelity of treatment—cannot
be so clearly identified. Although these are
more characteristic of evaluation studies than
randomized trials, such data would help to
inform future studies. In addition, assessment
of resilience and competence, designated as
integral to the strengths-based psychoeduca-
tional process, would contribute knowledge
regarding the unique and irreducible aspects of
the approach (Anderson et al., 1986; Cunning-
ham, 2000; McFarlane et al., 2003). These
include measures of the ability to act and
change, willingness to initiate change, appli-
cation to self-help work, and quality of rela-
tionships with others and everyday experience.
Other limitations can be identified in the
studies reviewed in terms of both conceptual
approach and research design. These include
issues regarding sampling strategies, sample
size, and statistical power; measurement (both
process and outcome); analysis; and clinical
definition. As regards sampling, several prob-
lems appear. There is almost no variability in
ethnicity within the studies reviewed, with the
exception of Kubany et al.’s (2003) work on
women who have been battered and suffer from
PTSD. In addition, only two of the studies
provide information on independence and
blindedness among assessment staff and de-
219
LUKENS AND MCFARLANE
scribe inclusion/exclusion criteria for study
participants (LeFort et al., 1998; Russell et al.,
1999).
Both specificity as to follow-up and efforts to
assess sustained impact of the interventions
over time are lacking in some of the studies
reviewed as well. Work is also needed to assess
when and for whom psychoeducational inter-
ventions do not work. Addressing these limi-
tations would involve identifying the
multideterminant and ‘‘optimal’’ measures for
each illness or set of circumstances for the
individual, family unit, individual family
members, and the community. Attending to
the profiles of those who reject or drop out of
this form of intervention is also critical.
Qualitative approaches may be needed to assess
subjective response to intervention, motiva-
tion, emotional availability, and readiness to
process information or participate in a group
intervention (Cunningham, 2000; McFarlane
et al., 2003).
Another factor that interferes with the ability
to replicate studies has to do with how the
investigators understand and present the clin-
ical determinants of psychoeducation in each
study. Given the breadth of applications cited
in this paper, it is inevitable that the docu-
mented interventions would vary greatly in
intensity, duration, and content. However, the
term psychoeducation is used inconsistently as
well, and at least one study referred to the
intervention as atheoretical (Bultz et al., 2000).
To address these inconsistencies, efforts are
needed to further articulate the common and
situation-specific aspects of psychoeducational
curriculum where possible, as well as structure,
duration, and organization of content (Cun-
ningham, 2000; McFarlane et al., 2003). As
specified in the APA task force on empirically
supported practice (Task Force on Promotion
and Dissemination of Psychological Procedures,
1995), access to a well-defined treatment
manual is essential as a precursor to measuring
220 Brief Treatment and Crisis Intervention / 4:3 Fall 2004
fidelity of treatment and to ensure potential for
efficacy and replication. Some established
investigators have addressed this by providing
access to their materials through the public
domain. For example, Sherman’s (2003) psycho-
educational curriculum for families of persons
with mental illness is available on the Internet,
and McFarlane’s work on psychoeducational
multiple family groups for schizophrenia is
available through the evidence-based practices
project sponsored by the Substance Abuse and
Mental Health Services Administration and the
Robert Wood Johnson Foundation (Steering
Committee, 2003).
Summary and Conclusions
In summary, this review indicates that psycho-
educational interventions have been applied in
a wide range of settings across system levels,
although to date only those addressing schizo-
phrenia and cancer can be considered evidence
based. A breadth of programs using this flexible
modality have emerged, as professional health
care workers have become increasingly aware
of the critical role that familial and other
informal sources of support play in health
outcome, successful functioning, and quality of
life in several illnesses. As medical and
psychiatric care have become less contiguous
and all aspects of medical care have become
more specialized and fragmented, continuity of
care and knowledge regarding individual sit-
uations has become increasingly difficult to
maintain and coordinate among professional
providers (Lasker, 1997). This has been wors-
ened by policy changes in the health care
environment involving managed care and in-
creasingly consolidated or truncated services
(House, Landis, & Umberson, 1988; McDonald,
Stetz, & Compton, 1996; Mechanic, 2002;
Pescosolido, Wright, & Sullivan, 1995).
Psychoeducational interventions appear to
be sufficiently flexible to circumvent some of

the dangers. To date, they have been used
successfully either as primary or adjunctive
treatment, as part of a strategic program for pre-
vention, or as an experiential training tool for
patients and their families in a range of settings
(Cunningham, Wolbert, et al., 2000; Lukens,
Thorning, & Herman, 1999; McFarlane et al.,
2003; Thase, 1997). However, additional efforts
are needed to fully define psychoeducation at
the clinical, community, and professional levels
as applied to various settings and populations,
and to further identify how emerging and state-
of-the-art professional knowledge can be in-
tegrated into such programs. Existing programs
that show preliminary success for conditions
other than schizophrenia or cancer must be
successfully replicated under rigorous condi-
tions before they meet the stringent criteria for
evidence-based practice laid out by the APA
(Chambless & Hollon, 1998; Task Force on
Promotion and Dissemination of Psychological
Procedures, 1995).
To better establish efficacy and effectiveness,
research designed to evaluate the impact of the
interventions on outcomes over time and in
a range of settings is critical. To conduct such
studies, clear and readily available treatment
goals and principles, carefully defined process
and outcome measures, and curriculum and
training manuals are needed to facilitate im-
plementation and replication by mental health
and health professionals, educators, and re-
searchers. At the individual and family level,
measures of outcome should include knowl-
edge, attitudes, social and vocational function,
self-efficacy and self-esteem, and other indica-
tors of quality of life and health. At the service
and community level, indicators should include
knowledge and attitudes among providers, and
documentation of health behaviors, service
access and use, and cost-effectiveness (Dixon
et al., 2000; Dixon et al., 2001; Lukens &
Thorning, 1998). At the policy level there are
two challenges: first, to assess readiness for
Brief Treatment and Crisis Intervention / 4:3 Fall 2004
Psychoeducation as Evidence-Based Practice
implementation, and second, to determine
acceptance and broad-based integration of the
approach at the service level (Cunningham,
2000; Dixon, Goldman, & Hirad, 1999; McFar-
lane et al., 2003).
Psychoeducation has the potential to extend
the impact of care provision well beyond the
immediate situation by activating and reinforc-
ing both formal and informal support systems
(Caplan & Caplan, 2000; Lundwall, 1996;
Pescosolido, Wright, & Sullivan, 1995) and
teaching individuals and communities how to
anticipate and manage periods of transition and
crisis. If developed and implemented carefully,
following specified guidelines for delivering
and documenting evidence-based practices
(Task Force on Promotion and Dissemination
of Psychological Procedures, 1995), psycho-
educational interventions have far-reaching
application for acute and chronic illness and
other life challenges across levels of the public
health, social and civic services, and/or educa-
tional systems.
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